This week, HMA principal Lori Raney, MD, provides an overview of telepsychiatry, a type of telemedicine where general psychiatric services are provided via videoconferencing, and how it can play a role in addressing the nationwide psychiatric workforce shortage. Dr. Raney highlights the opportunities for telepsychiatry in the market today, as well as identifies several of the obstacles to telepsychiatry implementation.

The Psychiatric Workforce Shortage

One in five people in the US will experience a behavioral health condition in their lifetime yet only 40 percent will receive any form of treatment. Behavioral health conditions and their impact on overall health outcomes and utilization have become a major focus for health care systems, and significant federal, state and private funding have been directed towards finding adequate and timely treatments. With behavioral health conditions now clearly recognized as contributing to a two to three fold increase in overall health care costs, and value-based payments and the Medicare Access and CHIP Reauthorization Act (MACRA) on the horizon, better solutions for timely and effective behavioral health care are needed now. In addition, health care reform efforts, including Medicaid expansion and the gradual reduction in stigma associated with having a behavioral health condition, have led to record numbers of people seeking treatment.

One of the obstacles to providing effective care is the shortage of psychiatrists, which has been an ongoing issue for several decades. Although efforts to increase the number of medical students selecting to train in psychiatry have been tried, this has not resulted in any significant increase due in part to low salaries and professional stigma. The shortage is further exacerbated by the desire for psychiatrists, like other specialty physicians, to live in more urban areas, leading to a geographical maldistribution of the workforce. Further complicating the problem is the fact that over half the psychiatrists in the country are over the age of 55 and looking at retirement in the next decade.

In more rural areas the situation is quite dire with 50 percent of counties without any behavioral health providers in any discipline and 95 percent of counties with a severe shortage of experts in prescribing psychotropic medications. This perfect storm of short supply and rising demand is hitting at a time when reform efforts desperately need innovative solutions.

Overview of Telepsychiatry

Telepsychiatry is a type of telemedicine where general psychiatric services are provided via videoconferencing. The service has been used for more than two decades. However, there was minimal uptake until the past several years when two things occurred; first, rising numbers of largely younger psychiatrists started to choose telepsychiatry as a predominant way to practice medicine, and second, the cost of technology to deliver the service declined dramatically. The growing trend has spawned the proliferation of over 30 companies now operating in this space with some companies reporting more psychiatrists applying than there are available positions. Telepsychiatry is being implemented in diverse locations including:

community mental health centers

primary and specialty care settings

skilled nursing facilities

emergency rooms

correctional settings, and

inpatient hospital sites.

In settings that have psychiatrists, it is being utilized to cut down on “windshield time” spent travelling across town or to satellite clinics, increasing appointment availability.

Telepsychiatry does not address the psychiatrist shortage per se as it does not add more psychiatrists to the overall pool. Instead, it offers a solution to the geographic maldistribution of the workforce allowing staff from more urban areas to beam into rural communities electronically. In addition, there is a growing trend in using telepsychiatry to also deliver consultative services in addition to direct care. This population-based approach, where the psychiatrist assists and supports other providers (such as primary care providers) in the treatment of mild to moderate behavioral health conditions, leverages scarce psychiatric resources to cover larger populations of those in need. One particular approach to this type of consultative service that could be adapted to telepsychiatry, known as the collaborative care model, has recently been selected by the Center for Medicare and Medicaid Services to be reimbursed in the 2017 Physician Fee Schedule after demonstrating robust results in a recent Center for Medicare and Medicaid Innovation (CMMI) grant-funded opportunity.

Telepsychiatry has an evidence base demonstrating:

it is comparable to in-person psychiatric care

it can reduce overall health care costs

it is widely accepted by patients and providers, and

direct-to-consumer care is a growing trend with many organizations already providing this service.

Challenges in Telepsychiatry Market

Barriers to implementation include funding and regulatory limitations that vary state to state, mostly due to outdated beliefs about telemedicine being less effective than direct evaluation or that the patient must receive telepsychiatry services in a medical clinic exclusively. Many states have current legislative agendas to remedy these limitations in order to meet the behavioral health needs of their population. Interstate physician licensure requirements stipulate the provider must have a license in the state where the patient resides, a process which can take 3-6 months to complete for an out-of-state physician. National organizations are working to push for changes and offer resources including readiness assessment tools and implementation guides. Some payers have required patients be physically located in clinic sites while others have offered lower reimbursement when services are delivered electronically. However, as acceptance of telepsychiatry has grown and demand for psychiatric services has continued to increase, changes in reimbursement practices have quickly followed.

Telepsychiatry, like all forms of medical care, requires careful selection of providers and telepsychiatry vendors. Understanding local internet capability and problem-solving bandwidth issues is important to success. Planning and adequate preparation for introducing any new model of care takes time and effort, and organizations looking for solutions to address their psychiatric behavioral health care needs with this modality should think of implementation as they would with any change management initiative.

For More Information

For questions or information on this brief, please contact Lori Raney, MD, at lraney@healthmanagement.com. Dr. Raney is a psychiatrist and Master Trainer in the collaborative care model of integrated care and its adaption to telepsychiatry.